REVIEW DO­I: 10.4274/jcrpe.galenos.2019.2019.

S0003
J Clin Res Pediatr Endocrinol 2020;12(Suppl 1):28-40

Contraception for Adolescents

Nicole Todd1, Amanda Black2
1Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada
2Department of Obstetrics and Gynecology, University of Ottawa; and The Ottawa Hospital Research Institute, Ottawa, Canada

Abstract
Although pregnancy and abortion rates have declined in adolescents, unintended pregnancies remain unacceptably high in this age group.
The use of highly effective methods of contraception is one of the pillars of unintended pregnancy prevention and requires a shared
decision making process within a rights based framework. Adolescents are eligible to use any method of contraception and long-acting
reversible contraceptives, which are “forgettable” and highly effective, may be particularly suited for many adolescents. Contraceptive
methods may have additional non-contraceptive benefits that address other needs or concerns of the adolescent. Dual method use
should be encouraged among adolescents for the prevention of both unintended pregnancies and sexually transmitted infections. Health
care providers have an important role to play in ensuring that adolescents have access to high quality and non-judgmental reproductive
health care services and contraceptive methods in adolescent-friendly settings that recognize the unique biopsychosocial needs of the
adolescent.
Keywords: Adolescent, contraception, family planning, long acting reversible contraception, counselling, contraceptive services,
pregnancy in adolescence/prevention and control

Introduction as the cultural and religious beliefs of the young woman;

providing evidence-based information on the effectiveness,
Adolescents, defined by the World Health Organization risks, and benefits of the different contraceptive methods;
(WHO) as individuals between the ages of 10-19 years (1), having technically competent trained health care workers;
represent almost one-fifth of the world’s population. During and having convenient access to a range of relevant services
adolescence, young people navigate numerous physical, (2). The WHO also states that no method of contraception is
cognitive, emotional, and behavioural changes as they contraindicated on the basis of age alone (4). These position
acquire increasing autonomy and experiment in many statements extend to adolescents who also have the right
areas. Experimentation may include alcohol or drug use,
to sexual and reproductive health services, including
smoking, and sexual activity, all of which may be associated
contraceptive care and counselling. However, access to
with sexual and reproductive health risks such as unintended
contraceptive education and information and the availability
pregnancy and sexually transmitted infections (STIs).
and accessibility of contraceptive methods may be affected
The United Nations and the WHO consider that access to by the complex dynamics of social, cultural, political, and
safe, voluntary family planning is a human right because religious influences, particularly for adolescents.
it is essential for promoting gender equality, advancing
the autonomy of women, and reducing poverty (2,3). The
Sexual Behaviour and Unintended Pregnancy
WHO has identified key elements in quality of care in family
planning which include: having choice among a wide range In most Western countries, the median age of first
of methods; patient-provider relationships based on respect intercourse is around 17 years. By age 18, 60% of females
for informed choice, privacy, and confidentiality as well will have had sexual intercourse and by age 20 years

Address for Correspondence: Amanda Black MD, Department of Obstetrics and Conflict of interest: Dr. Amanda Black: In the past
Gynecology, University of Ottawa; and The Ottawa Hospital Research Institute, 5 years, Dr. Black has received honoraria for advisory
Ottawa, Canada board participation and as an invited speaker from Bayer
Phone: +613-738-8400/81799 E-mail: [email protected] Pharma AG, Pfizer, Merck, and Actavis.
ORCID: orcid.org/0000-0002-2245-3428
Dr. Nicole Todd: In the past 5 years, Dr. Todd has
©Copyright 2020 by Turkish Pediatric Endocrinology and Diabetes Society
received speaking honoraria from Bayer Pharma AG.
The Journal of Clinical Research in Pediatric Endocrinology published by Galenos Publishing House.
Received: 30.12.2019
Accepted: 08.01.2020

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2020;12(Suppl 1):28-40 Contraception for Adolescents

almost 80%. Many have had more than one partner contraindications on recommendations for contraceptive
(5,6,7,8). Adolescents have the lowest level of contraceptive use, by delaying initiation of contraception unnecessarily (i.e.
knowledge and use (9). Initiation of sexual activity while they waiting until the next menses or until STI screening results
lack adequate knowledge and skills to protect themselves are available), by requiring unnecessary investigations prior
places adolescents at higher risk of unwanted pregnancy, to contraceptive initiation (i.e. by erroneously insisting on a
unsafe abortion, and STIs (10). Although there appears to be Pap smear prior to starting contraception), or by perpetuating
an increase in contraceptive use at first intercourse, many unfounded myths about contraceptive use (18). HCPs should
adolescents still do not use any method of contraception ensure that they have the necessary skills and knowledge
at first intercourse or do not continue to use contraception to provide unbiased, non-judgemental, evidenced-based,
consistently (7,11). The most commonly used method of adolescent-friendly sexual health and reproductive health care
contraception at first intercourse is the male condom, which and to be able to dispel common myths and misperceptions
is important from the STI prevention perspective but is less about contraceptive use (Table 1) (9).
reliable as a contraceptive method due to typical use failure
The cost of contraception services and methods is a potential
rates that are significantly higher than those seen with other
barrier for adolescents. Contraception may be prohibitively
contraceptive methods (12).
costly for an adolescent and the need for parental financial
Unintended pregnancy in adolescents can have major assistance may compromise confidentiality. Although
consequences for the young woman, her family, and society. contraception is provided at no cost in some countries,
The use of effective contraceptive methods is a cornerstone in other countries contraception is covered by private
of adolescent pregnancy prevention. Although adolescent healthcare and/or by the patient paying directly. Provision
pregnancy rates are decreasing worldwide, adolescent of contraception at no cost may remove one financial
mothers make up 11% of births (13). Although there are barrier but does not guarantee high rates of utilization.
variations in cultural norms around age of marriage and Nonetheless, universal subsidies for contraception appear
childbearing, the majority of adolescent pregnancies are to be cost-effective (25). The annual direct cost estimates
unintended (9,14,15). Adolescent pregnancy contributes for unintended pregnancy are $320 million in Canada and
to maternal and child mortality, with complications from $4.6 billion in the United States (26,27). Contraceptive non-
pregnancy and childbirth being the leading cause of death adherence accounts for 69% of this cost. Cost models have
for girls aged 15-19 years (13). Adolescents who give birth shown that provision of/switching to long-acting reversible-
face significant socioeconomic challenges. Adolescents at contraceptives (LARC) would reduce contraceptive failures
greater risk of unintended pregnancy include those who are and lead to cost neutrality within 12 months (26,27). The
living in poverty, with low education and fewer employment Contraceptive CHOICE Project determined that provision of
opportunities, and marginalized populations. Pregnancy free contraceptives to adolescents reduces teen pregnancy,
itself is an important opportunity to counsel on future teen birth, and abortion (28) while yielding significant cost
contraceptive plans, as rapid repeat pregnancy is common savings (29). The CHOICE Project also found that when cost
among adolescent mothers (16). The Centers for Disease is removed, the majority of adolescents (~70%) would
Control (CDC) Medical Eligibility Criteria for Contraceptive choose LARC.
Use (MEC) provides guidance on post-partum contraceptive
options (17). Contraceptive Counselling
There should be no restrictions on the ability of adolescents
Barriers to Contraceptive Access and Use
to receive complete and confidential contraceptive services.
Barriers to accessing contraceptive information and methods An assurance of confidentiality will increase the willingness
include social or culture taboos, legal restrictions, health of adolescents to disclose sensitive health information and
care provider (HCP) attitudes, and healthcare systems seek health care advice, while a loss of confidentiality can
(9,10). The acceptability and availability of contraception for negatively impact an adolescent’s participation in sexual
adolescents varies by region and even by countries in the health services (30). Confidentiality, including its scope
same region. Adolescents may experience barriers accessing and limits, should be discussed with adolescents and
contraception including inconvenient medical clinic hours, caregivers, and reiterated once the adolescent is alone.
financial restrictions, lack of confidentiality, and lack of Regrettably, adolescents’ legal rights to confidential family
provider training. HCPs themselves may act as medical planning services vary by region and change over time
barriers by imposing their own personal values/moralistic (31). Adolescents should also be aware of instances where
beliefs on the adolescent, by applying inappropriate medical confidentiality may need to be breached (32). HCPs should

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consult local laws regarding confidentiality and age of further questions (34). Another approach to contraception
consent, which may vary by region. An adolescent’s choice counselling can be found in Table 2. Adolescents should
of contraception should be respected, and contraception be asked about intimate partner violence, and specifically
should never be coercive. about reproductive coercion.
The clinic should be welcoming to adolescents, ideally with HCPs should counsel on all available contraceptive options
flexible scheduling, convenient times (timed around school), without bias. Effectiveness, advantages and disadvantages
and age appropriate visual aides (33). Scheduled follow-up should be discussed. Adolescents should be advised that
visits are important to ensure method acceptability and failure rates are highest for user dependent methods
ongoing contraceptive adherence. (e.g. natural family planning, withdrawal, condoms, oral
contraceptives) (12). LARC methods act continuously and
HCPs should engage in a shared decision making process
are less user-dependent [e.g. contraceptive implants and
with adolescents. There are many suggested approaches
to contraception counselling. The CDC suggest that intrauterine contraceptives (IUCs)]. A recent Cochrane
sexual history taking should include the “5Ps”: Partners, review did not find significant differences amongst hormonal
Practices, Protection from STIs, Past history of STIs, contraception, levonorgestrel releasing system (LNG-IUS),
and Pregnancy Prevention (33). This can help HCPs and copper intrauterine device (Cu-IUD), although the studies
and adolescents work toward a contraceptive plan that were small, and of low to moderate quality (35). Anticipatory
is focussed on anticipatory guidance, education, and discussion around anticipated menstrual side effects can
disease prevention. Another approach to contraception reduce discontinuation of the shorter acting methods (36).
counselling is the “GATHER” approach where the HCP The WHO has developed a tiered system to discuss
Greets and builds rapport, Asks questions and listens, contraception (Figure 1) (37):
Tells her relevant information to help her make an
Tier 1: LARC are methods that do not rely on the user.
informed choice, Helps make a decision and provides
other related information, Explains the method in detail Tier 2: Methods that rely on consistent use daily (pill),
including its effectiveness, potential side effects, and how weekly (patch), every three weeks (vaginal ring), every three
to use it, and lastly has the patient Return for advice or months depo-medroxyprogesterone acetate (DMPA).
Table 1. Contraceptive myths and misperceptions
Myth Fact
The COC pill causes weight gain and acne Placebo-controlled trials have not shown an association between COC use and
weight gain. Acne improves in most women using COCs due to a decrease in
circulating free androgens
A pelvic exam is required prior to initiating With the exception of an IUC (which requires a pelvic exam for insertion), pelvic
contraception examination is not required prior to starting a contraceptive method
It is important to “take a break” from the COC It is not necessary to take a “pill break”. Unless medical conditions arise that
every few years contraindicate its use, the COC may be continued until pregnancy is desired or a
woman wishes to switch to another contraceptive method
COCs and IUCs can affect future fertility When COCs or IUCs are discontinued, a woman quickly returns to her baseline
fertility
IUCs cannot be used in adolescents or in IUCs can be safely used by adolescents and nulliparous women
nulliparous women
IUCs increase the risk of ectopic pregnancy IUCs work primarily by preventing fertilization so IUC users have half the risk of
ectopic pregnancy compared to women not using contraception (19)
IUCs do not have any non-contraceptive benefits The LNG-IUS is associated with a decrease in menstrual flow and less menstrual
cramping. All IUCs are associated with a decreased risk of endometrial cancer
(20)
COCs cause cancer COCs are associated with a decreased risk of endometrial and ovarian cancer
and potentially colorectal cancer. The risk of cervical cancer may be increased in
COC users compared with non-users. Data on breast cancer risk with COC use
is conflicting but many studies have failed to demonstrate an increased risk of
breast cancer or breast cancer mortality in COC users (21,22,23)
IUCs can only be inserted during menses An IUC can be inserted at any time during the menstrual cycle provided that
pregnancy or the possibility of pregnancy can be ruled out (24)
COC: combined oral contraceptive, IUC: intrauterine contraceptive, LNG-IUS: levonorgestrel-releasing intrauterine system, IUCs: intrauterine contraceptives

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Tier 3: Methods that rely on user during sexual activity (male while respecting her personal beliefs, culture, preferences,
and female condom, spermicide, natural family planning), or and ability to be adherent (25).
immediately after [emergency contraception (EC)].
Age alone is not a contraindication to any contraceptive
Many international organizations have recommended method (2,32,41). HCPs should address common myths
moving to a tiered approach to contraceptive counselling, and misperceptions (Table 1) as well as common side
whereby HCPs present contraceptive options in order of effects. Adolescents may fear weight gain, bleeding, acne,
contraceptive effectiveness and start the contraceptive and mood side effects, while their parents may fear effects
discussion with Tier 1 LARC methods (8,33,38). on future fertility and the risk of cancer. Regardless of the
Contraceptive effectiveness is one of a woman’s most method of contraception chosen, adolescents should be
important considerations when choosing a contraceptive counselled on the importance of the use of latex condoms
method (39) and using top tier methods would achieve to reduce the risk of STI acquisition (dual method) (25,38).
the highest effective contraception. However, while
effectiveness is a paramount characteristic, it is important
Starting Contraception
that tiered counselling focused on “LARC-first” does not
become too directive or coercive, particularly in vulnerable Most contraceptive methods can be initiated at any time
populations (40). In a rights-based family planning during the menstrual cycle provided that pregnancy or the
framework, the choice of contraception should be made in possibility of pregnancy can be ruled out (Table 3) (41,42).
collaboration with each individual adolescent taking into The “Quick Start” method refers to starting a method
account safety, effectiveness, accessibility, and affordability immediately rather than waiting for the next menstrual
Table 2. Contraceptive counselling in the adolescent
Be Welcoming
- Use adolescent friendly language and material
- Acknowledge the need for confidentiality
- Remain unbiased and non-judgmental
What to Ask
- Reproductive and sexual history, including previous and current use of contraception
- Medical history including any specific medical conditions or medications that may be contraindications to contraceptive use
- Her current relationships, partners, and whether she has any concerns
- What is she currently doing to prevent pregnancy?
- How important is it to her to avoid pregnancy currently?
- Her ability and motivation to use contraception regularly and correctly
- Her needs and expectations from a contraceptive method
- The level of support she has at home or from her partner
- Whether she needs to hide her use of contraception
- Would she prefer to have periods or to not have periods?
Be Sure to Check
- Her awareness of methods and whether she already as a preference
- The accuracy of her knowledge
- Methods matching her needs and expectations have been discussed
- The identified potential options are acceptable to her
- How will she pay for contraception?
- Is STI screening appropriate?
- Does she have any fears or concerns?
What to Tell
- How the method works, how effective it is, how to use it consistently and correctly, what to do if they miss/are late for a dose,
and when to seek medical attention?
- How it will affect her menstrual cycle?
- What are the non-contraceptive benefits?
- Potential side effects and what to do if they occur?
- When to return for a follow-up visit?

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period. Waiting to initiate contraception may place an Adolescents who choose to Quick Start contraception when
adolescent at an increased risk of unintended pregnancy. a very early pregnancy cannot be completely excluded can
Starting contraception immediately/at the time of the visit, be reassured that current evidence does not demonstrate
has been associated with improved short-term compliance an adverse impact of contraceptive hormone exposure on
and is not associated with an increased incidence of either fetal development or pregnancy outcomes (45,46).
breakthrough bleeding or other side effects (43,44). When When using the Quick Start method, back-up contraception
the possibility of pregnancy is uncertain, the benefits of (barrier method and/or abstinence) should be used for the
starting a combined hormonal contraceptive (CHC) (CHC: first seven consecutive days of contraceptive use unless it is
COC, vaginal contraceptive ring, contraceptive patch) likely initiated on the first day of menses (42). Adolescents may
exceed any risk. Thus CHC can be started immediately choose to start hormonal contraception on the first day of
and a follow-up pregnancy test arranged in 2-4 weeks. the next menstrual cycle or do a “Sunday start”. Starting on
the first day of the menstrual cycle allows an adolescent to
Table 3. Criteria for being reasonably certain a woman is be reasonably sure that they are not pregnant. Initiating on a
not pregnant Sunday allows for a withdrawal bleed to occur on a Monday,
A woman has no signs or symptoms of pregnancy and meets assuming a seven-day hormone-free interval (HFI). CHCs,
one of the following criteria:
injectable progestins, or contraceptive implants may be
- Is ≤7 days after the start of a normal menses
started immediately after a surgical or medical pregnancy
- Has not had sexual intercourse since the first day of her
last normal menses termination (47). An IUC can be inserted immediately after
- Has been using a reliable method of contraception first or second trimester abortion.
consistently and correctly
In asymptomatic patients, there is no requirement for a
- Is ≤7 days post-abortion (spontaneous or induced)
pelvic exam prior to initiating contraception. Pap smear
- Is <4 weeks post-partum
- Is exclusively breastfeeding, amenorheic, and <6 months
screening recommendations have changed in recent years
post-partum and vary by region, but most no longer advocate for Pap
If any of the above criteria are met, a pregnancy test is not smear screening in adolescents; some bodies recommend
required. In most other cases, a negative high sensitivity urine delaying screening until age 21 in sexually active women
pregnancy test will reasonably exclude pregnancy
while others endorse delaying Pap smear screening until age
Ref. 41.
25. STI screening can be accomplished with urine sample

Figure 1. World Health Organization Tiered approach to contraceptive effectiveness

*Adapted from Family Planning: A Global Handbook for Providers (2018 Update) (37)
IUD: intrauterine device

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for polymerase chain reaction, self-collection swabs, or may be more effective than LNG-EC in obese adolescents
cervical swab collection. STI screening is not a requirement (50). There are no absolute contraindications to EC, aside
prior to IUC placement. STI screening may be performed from pregnancy or previous sensitivity reactions. Use of a
on the day of IUC insertion but insertion should not be Cu-IUD for EC has the same eligibility criteria as routine Cu-
delayed while waiting for the results, provided that there are IUD insertion (2,41).
no overt signs of infection. HCPs should provide at least a
LNG-EC, UPA-EC, and mid dose mifepristone are all more
year-long prescription and should consider having samples
effective than the Yuzpe method although all methods have
on site to provide to adolescents (38). All adolescents should
been shown to decrease pregnancy rates (49). The Cu-IUD
be counselled on how long to use back up contraception
causes an inflammatory reaction that is toxic to oocytes,
after starting a new contraceptive method. The Cu-IUD is
spermatozoa, and increases smooth muscle activity in
effective immediately while CHC methods, the single rod
fallopian tubes and myometrium preventing implantation.
implant, the LNG-IUS, and DMPA are effective after seven
Hormonal EC works by impairing follicular development
consecutive days of use. Additional information on what
of the dominant follicle provided they are taken prior to
to do if they miss/delay taking their contraceptive method
ovulation. LNG-EC is preferred over the Yuzpe method
should be provided.
owing to higher effectiveness - up to 85% if used within
72 hours. UPA-EC is more effective than LNG-EC likely due
Non-contraceptive Benefits to its ability to disrupt ovulation even if taken after the
LH surge has begun. For adolescents using LNG-EC or the
Counselling on contraceptive options should also include
Yuzpe regimen, hormonal contraception can be resumed
discussion about non-contraceptive benefits. Hormonal
immediately. In the case of UPA-EC, initiation of hormonal
methods can provide improvement in heavy menstrual
contraception should be delayed for five days due to potential
bleeding (HMB) and dysmenorrhea. CHC can also improve
interactions between the two medications that may affect
cycle regularity, acne, hirsutism, and premenstrual
effectiveness and UPA-EC’s ability to delay ovulation (51).
symptoms. Adolescents may prefer concealed options such
Backup contraception and/or abstinence should be used
as injectables, implants or IUC.
until hormonal contraception has been taken for at least
seven consecutive days. On the other hand, the Cu-IUD is
Emergency Contraception immediately effective for ongoing contraception. EC users
should have a pregnancy test if spontaneous menses do not
Regardless of the contraceptive method they choose,
occur within 21 days of EC use, if the next menstrual period
adolescents should be aware of EC and know that it can be
is lighter than usual, or if it is associated with abdominal
used in the setting of contraceptive failure, such as condom
pain not typical of the woman’s usual dysmenorrhea. If a
interruption, non-adherence to hormonal contraception,
pregnancy occurs in a cycle during which oral EC was taken,
or no contraceptive method used. HCPs should write
the adolescent should be advised that there does not appear
prescriptions for EC, and provide information on how and
to be a harmful effect on pregnancy outcomes and there is
when to access EC. Hormonal EC is available in many
no increased risk of congenital abnormality (48).
countries without a prescription. Increased availability of
hormonal EC does not increase the frequency of unprotected EC is a useful back-up method for condom use: if the condom
intercourse (UPI), the likelihood of sexual risk-taking, or breaks, slips, or is not used, there is still a further possibility
make women less likely to use effective contraception (48). of preventing pregnancy. However, the efficacy of hormonal
Available EC options include: LNG-EC, 1.5 mg orally x 1 EC is significantly lower than regular use of contraception
dose, high dose CHC (Yuzpe method), ulipristal acetate (UPA) and its preventive efficacy should not be overestimated. In
(UPA-EC, 30 mg orally x 1 dose), mifepristone (low, mid most clinical scenarios, EC provision should be considered
dose) and insertion of Cu-IUD (25,49). The most effective an opportunity for counselling and to start a continuous
EC is the Cu-IUD, which can be used up to seven days and effective contraceptive method as soon as possible (5).
after UPI provided a pregnancy test is negative. It also has Quick Start is described previously.
the additional benefit of ongoing contraception; however
adolescents may experience barriers accessing a provider
Medical Eligibility Criteria for Contraceptive Use in
within the recommended time window (25,32). Hormonal
Adolescents
EC can be offered up to 120 hours after UPI or contraceptive
failure, although LNG-EC is more effective the sooner it is Although age itself is not a contraindication to the use of any
taken. UPA-EC may be used up to five days after UPI and method of contraception, reversible contraceptive methods

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are generally preferred in adolescents. Guidance for the safety failure rates and high one-year continuation rates. IUC rates
of contraceptive use in women with certain characteristics have a 99% efficacy, with over 80% continuing with the
or medical conditions are provided in the form of MEC from method at one year (54). There are two types of IUCs: Cu-
the WHO, the CDC, the Faculty of Sexual and Reproductive IUD and LNG-IUS. The Cu-IUDs may either have a frame
Healthcare, and other international organizations (4,17,52). (usually T-shaped) or be frameless and contain a varying
For each medical condition/characteristic, contraceptive amount of copper. The LNG-IUS’s (LNG-IUS 20, LNG-IUS 12,
methods are placed in one of four categories to determine LNG-IUS 8) contain different amounts of levonorgestrel in
contraceptive eligibility (Table 4). The WHO and CDC their reservoir. The main mechanism of action of all IUCs is
also developed Selective Practice Recommendations for the prevention of fertilization.
Contraceptive Use that recommend which tests and exams
Prior to providing or placing an IUC, absolute and
should be performed prior to providing contraception (2,41).
relative contraindications should be reviewed. There is
Breast, pelvic and genital examination, Pap smears, and
no requirement for pre-placement ultrasound. HCPs may
bloodwork are not recommended routinely because they do
require additional training for insertion. The success rate
not contribute to increased safety of CHC use. Ideally, blood for insertion in adolescents is 96% (56). Adolescents may
pressure and body mass index (BMI) should be recorded choose the LNG-IUS for its non-contraceptive benefits
for adolescents prior to starting CHC but should not delay that include a reduction in menstrual bleeding and
initiation of contraception. A medical history should be dysmenorrhea. The LNG-IUS 20 (Mirena®) is approved for
taken to alert HCPs to conditions or risk factors that might treatment of HMB, and may prove beneficial for adolescents
be a contraindication to contraceptive use. with HMB, bleeding disorders, and those on anti-coagulation
(57). Although the LNG-IUS has less systemic absorption
Contraceptive Options for Adolescents compared to CHCs, some adolescents experience hormonal
side effects including acne, breast tenderness, headaches,
Intrauterine Contraception
and mood changes. Functional ovarian cysts may occur in
IUCs are LARC methods that are highly effective and can LNG-IUS users, however these cysts are often asymptomatic
be used by women of any age. Neither age nor nulliparity and do not require further intervention (54). Adolescents
are contraindications to their use although rates of IUC choosing a Cu-IUD may be seeking a LARC method with
expulsion are significantly higher in adolescents compared minimal hormonal exposure. Cu-IUD users may experience
to older women regardless of parity or IUC type (4,53). increased menstrual blood loss and dysmenorrhea.
Many international societies have stated that IUCs are a Adolescents can be offered non-steroidal anti-inflammatory
safe first line choice for adolescents (8,31,32,38,54,55) and drugs (NSAIDs) and/or tranexaminic acid to help decrease
encourage HCPs to counsel all adolescents on their use for menstrual blood loss and dysmenorrhea. With time, the
the prevention of pregnancy due to their low typical use- number of unscheduled bleeding days tends to decrease
Table 4. Medical Eligibility Criteria categories for with both LNG-IUS and Cu-IUD users. Occasionally IUC users
contraceptive use may request IUC removal due to ongoing dysmenorrhea.
Category Definition of category HCPs should counsel the adolescent about IUC insertion
1 No restriction on the use of the contraceptive and not rush. Handouts may be helpful and can include
method.
information about the need for ongoing condom use to
2 The advantages of using the method generally protect against STIs, duration of back-up contraception
outweigh the theoretical or proven risks.
after insertion (seven days for the LNG-IUS, none required
The method can generally be used but more careful
follow-up may be required. for Cu-IUD), recommendations for prophylactic NSAIDs for
3 The theoretical or proven risks usually outweigh the insertion, common initial side effects such as cramping
advantages of using the method. or unscheduled bleeding, and when to seek medical
Use of the method requires expert clinical assessment. Pre-placement NSAIDs have been shown
judgement and/or referral to a specialist to reduce discomfort post-insertion. Currently, there is
contraceptive provider because use of the method
is not usually recommended unless other more no evidence to support routine pre- and post-placement
appropriate methods are not available or not ultrasound. Although in selected cases vaginal and/or
acceptable. oral misoprostol taken pre-procedure may help with IUC
4 There is an unacceptable health risk and the insertion, its routine use should be discouraged due to an
method should not be used. increase in side effects such as bleeding, abdominal pain
Ref. 4,17,41,52
and cramping, fever, and higher pain scores post-IUC

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insertion (58). Paracervical blocks may reduce pain with effective for up to four years, and high continuation rates
tenaculum placement, but have not been shown to reduce are seen at one and two years (28,60,61). Its contraceptive
pain with IUC insertion. Smaller diameter LNG-IUS’s (LNG- effect is due to cervical mucous thickening, thinning of
IUS 12, LNG-IUS 8) and Cu-IUDs may be associated with endometrial lining, and ovulation inhibition. The most
less pain on insertion. Adolescents should be offered IUC common side effect is unscheduled bleeding which is
placement in the clinician’s office, and routine insertion variable and does not necessarily improve with time.
in the operating room should be avoided unless this is the Implant users requesting removal often cite abnormal
adolescent’s preference. Prior to IUC placement, the HCP uterine bleeding, weight gain, or acne as the reason
should rule out the possibility of pregnancy (Table 3). for removal (62). Functional cysts can be seen in users,
IUCs are not associated with an increased risk of pelvic but usually do not require further intervention (60). The
inflammatory disease or STI acquisition although there is a implant does not have an adverse effect on bone mineral
small increased risk of pelvic infection seen within 21 days density (BMD) such as that seen with DMPA, likely owing
of IUC placement (59). STI screening should be performed to ongoing ovarian activity that allows for endogenous
in women at high risk of STIs prior to or at the time of estradiol to support bone health, but there is limited
insertion but it is not necessary to delay IUC insertion until evidence in adolescents. This Tier 1 method may be
the results are available. Positive results can be treated while a good option for adolescents because it is non-coitally
the IUC remains in situ (54). Routine antibiotic prophylaxis dependent, does not require daily user action, and is
at the time of IUC placement is not recommended. IUCs can discrete. Advantages of this LARC include 3-year duration
safely be used in adolescents with a history of STI, including of effectiveness, reversibility, discretion, and can be used
human immunodeficiency virus (HIV), although insertion by adolescents who have contraindications to estrogen.
should be delayed if there is evidence of mucopurulent It can be seen on X-ray. Contraceptive implants can be
discharge. Immunosuppression is not a contraindication to inserted post-abortion, and immediately post-partum
IUC use (4,8). thereby reducing rapid repeat pregnancy and repeat
abortions among adolescents (63).
IUCs may be safely inserted in the immediate post-abortion
and post-partum period (delivery to 48 hours). While there
B) DMPA
may be a slightly higher expulsion rate (10%), this should
DMPA-IM is an intramuscular injection that is administered
not be a barrier to offering placement. Immediate post-
placental insertion should not be offered in the setting of every 12 weeks by a HCP. A lower dose subcutaneous
chorioamnionitis and/or post-partum hemorrhage. version (DMPA-SC) that can be self-administered is available
in some countries. DMPA inhibits pituitary gonadotropins,
leading to anovulation and causes thickening of cervical
Progestin-only Contraceptive Options mucous. Advantages of this method include discretion,
Progestin-only contraceptives do not contain estrogen and infrequent dosing, and non-contraceptive benefits
thus may be good options for young women who cannot take such as reductions in dysmenorrhea, premenstrual
estrogen. There are few contraindications to progestin-only symptoms, HMB, fibroids, anemia, seizures, and sickle
methods: current breast cancer (Category 4), breast cancer cell crises (8,60). It is one of the few systemic hormonal
remission within five years, severe cirrhosis, hepatocellular contraceptives that can be reliably used with liver-enzyme
adenoma, malignant liver tumour, and unexplained vaginal inducing drugs because its concentrations are not affected
bleeding (Category 3) (4,17,60). Non-contraceptive benefits (5). Disadvantages may include having to access a HCP for
of progestin-only options include decreased dysmenorrhea intramuscular injections, unscheduled bleeding, delayed
and endometriosis-related pain. The most common return to fertility, and weight gain. Adolescents using
side effect is unscheduled bleeding. All progestin-only DMPA appear to gain more weight than non-users or users
contraceptive options are safe for adolescents, with the of other contraceptive methods (64). Adolescents who
implant being a WHO Tier 1 contraceptive method (37). experience more than a 5% weight gain after six months
of DMPA use may be at risk of continued excessive weight
A) Contraceptive Implant gain (65). DMPA has high rates of amenorrhea, with up
The single rod implant containing etonogestrel, an active to 68% of DMPA users being amenorrheic at 24 months.
metabolite of desogestrel, is the most effective method Although unscheduled bleeding may decrease in amount
of reversible contraception with an efficacy of 99%. It is and frequency with time, irregular bleeding is a common
effective in situ for up to three years, although it is likely reason for discontinuation.

35
Todd N and Black A J Clin Res Pediatr Endocrinol
Contraception for Adolescents 2020;12(Suppl 1):28-40

DMPA use can be associated with a reversible BMD loss, Combined Hormonal Contraception
likely due to the estrogen deficiency that accompanies its
use (66). This may be of concern in adolescence, when CHC methods contain an estrogen and a progestin. They
bone accrual should be occurring (67,68). The BMD loss include the pill, patch, and vaginal ring. In the absence
associated with DMPA use is greatest in the first one to two of medical contraindications adolescents can safely use
years which has led several organizations to recommend CHC. Absolute and relative contraindications should be
a maximum duration of use of two years. The bone loss reviewed prior to initiation (4,17). Common side effects
seen with DMPA use is similar to bone loss seen with including unscheduled bleeding, nausea, and headaches,
pregnancy and appears to return to baseline within two should be discussed with the adolescent prior to initiation,
years of discontinuation (69,70). Both the American as this improves continuation (36). Adolescents and young
College of Obstetricians and Gynecologists and the women can be counselled that they can take the CHC with
Society of Obstetricians and Gynaecologists of Canada a 4- or 7-day HFI, and/or can take cyclically or in extended
have recognized the risks of unintended pregnancy in cycle (Skipping periods). Benefits of extended cycle use
adolescents if their contraceptive options are limited and include reduction in dysmenorrhea, HMB, acne, anemia,
hence have stated that there should no restriction on and conditions exacerbated by cyclic variations (e.g.
the use of DMPA or duration of use in women who are migraine without aura, epilepsy, irritable bowel syndrome,
otherwise able to use the method (60,71). The WHO has inflammatory bowel disease, mood, behaviour) (8,75).
determined that for females younger than 18 years, the Women taking CHC in extended cycle either experience
advantages of using DMPA generally outweigh the theoretic equivalent or less unscheduled bleeding compared to
safety concerns regarding fracture risk (72). cyclic counterparts (75). Extended/continuous cycles can
be achieved by using the hormone for two, three, or more
Routine BMD monitoring is not recommended in
cycles back-to-back, without taking a HFI and having
adolescents using DMPA because dual energy X-ray
a withdrawal bleed. The safety of this approach is well
absorbtiometry has not been validated in these populations.
established and adolescents should be counselled that not
Although studies have demonstrated that low dose estrogen
experiencing bleeding during a HFI is safe, as evidenced
supplementation limits BMD loss in adolescent DMPA users,
by equivalent endometrial assessment via ultrasound and/
it isn’t recommend because of potential adverse effects and
or endometrial biopsy (75). For contraceptive efficacy, a
because there is lack of clinical evidence for the prevention
HFI should not be taken until at least 21 consecutive days
of fractures in the adolescent population (71). Adolescent
of hormonal contraception has been used. It is helpful to
DMPA-users should be counselled on adequate calcium and
provide adolescents with written instructions or website
vitamin D, weight bearing activity, and avoidance of alcohol,
links on how to take CHC in extended cycle, and what to
caffeine, and smoking which can be associated with BMD
do if a dosage is missed. Follow-up should be scheduled at
loss. HCPs should discuss the overall risks and benefits with
one and three months to ensure the method is acceptable
DMPA users at regular intervals.
and to assess side effects.
Recently, the WHO reviewed concerns about potential
A. Combined Oral Contraceptive (COC) pills are the most
increased HIV acquisition in DMPA users. They determined
popular hormonal contraceptives among adolescents.
that for women at high risk of HIV acquisition there are
Typical use failure rate is 9% (12) and is usually secondary
no restrictions for use of reversible methods (73). A recent
to non-adherence. Adolescents should be counselled on
randomized controlled trial did not find an increased risk of
behaviours to increase contraceptive adherence including:
HIV acquisition amongst Cu-IUD, DMPA-IM, or LNG implant
regular schedule, phone alarm, and family member support
users (74).
(8,9). Adolescents should be provided with resources (paper,
C) The Progestin-only Pill (POP) app, online) to assist when pills are missed.
The POP is taken every day, without a HFI. This method B. The Contraceptive Patch should be placed on the
works via thickening cervical mucous with anovulation seen buttocks, upper arm, upper torso, or abdomen once weekly
in only 50% of user. Adolescents should be counselled that for three weeks. During the HFI in the fourth week, a
POP needs to be taken at the same time every day to avoid withdrawal bleed usually occurs. In obese adolescents, there
pregnancy risk. It is often used as post-partum contraception may be a slightly higher risk of failure with the patch (76) but
when women are breastfeeding. Users may continue to obesity is not a contraindication to use of the contraceptive
have regular cycles, however, unscheduled bleeding is the patch (4,17). It can be used continuously for menstrual
most common reason for discontinuation suppression if desired.

36
J Clin Res Pediatr Endocrinol Todd N and Black A
2020;12(Suppl 1):28-40 Contraception for Adolescents

C. The Vaginal Contraceptive Ring is inserted into the osteoporosis or fracture in CHC users (72,85). Early data has
vagina by the adolescent and should remain in the vagina suggested that in healthy adolescents, COCs with at least
for three weeks (21 days), although pharmacokinetic data 30 mcg ethinyl estradiol may be preferred due to poorer
indicate that it is effective for at least 28 days (77). When bone mineralization seen with lower dose options (38),
the ring is removed, the adolescent can choose to have a and that extended regimens may be preferred to 28-day
4- to 7-day HFI or she can insert a new ring immediately to cyclic regimens because there is greater bone accrual (86).
avoid having a withdrawal bleed. At no time should the HFI Adolescents with eating disorders are at risk for decreased
exceed seven days. The ring can stay in the vagina during BMD. Although a recent study suggested COC use was
sexual intercourse but if the adolescent does wish to remove associated with normalization of bone resorption markers in
it during intercourse, it should not remain out of the vagina adolescents with anorexia nervosa and may limit bone loss
for more than three hours (42). (87), CHCs are generally not recommended for prevention
of osteoporosis in this population (32).
Considerations with Combined Hormonal Contraceptive v. Obesity: There are no contraindications to CHC use
based on body weight and/or BMI alone (17,42). Studies
i. Weight gain: A Cochrane review did not find a significant
demonstrate either equivalent or increased pregnancy rates
association between COC or transdermal CHC and weight
among obese CHC users, however more high quality studies
gain (78). There is currently insufficient evidence to link
are needed (88).
CHC use with weight gain. When counselling adolescents
about weight gain, it is important to discuss ongoing physical
development, and average weight changes for women over Barrier Contraception
a year.
Male condoms are the most commonly used contraceptive
ii. Mood: Data on CHC effect on mood is conflicting. Placebo- method at first intercourse, and one of the most commonly
controlled trials have not demonstrated a significantly used methods among adolescents (9). This method retains
increased risk of mood changes in CHC users compared with its popularity due to its low costs and lack of need for a
placebo users, and there is some evidence that COCs are prescription. Typical use failure rates are as high as 18%
protective for mood (79). COC’s containing drosperinone are and may be higher in adolescents due to inconsistent/
associated with an improvement in premenstrual dysphoric incorrect use (8,89). HCPs can help ensure that adolescents
disorder symptoms (80). Conversely, a large Danish understand proper condom use including sizing, placement,
prospective cohort study found an increased risk for first storage, and safe lubricants as well as how to negotiate
use of an antidepressant and first diagnosis of depression condom use with their partners (32,89). There are concerns
among users of different types of hormonal contraception, that adolescents choosing LARCs have the lowest rates
with the highest rates among adolescents (81). HCPs should of dual method use (90). Regardless of the contraceptive
counsel adolescents that CHC may be associated with mood method chosen, HCPs should encourage adolescents to
changes, but there is no conclusive evidence linking CHC to continue to use condoms for STI prevention as well as
depression (32). contraceptive back-up in the event of a contraceptive failure
and/or non-use.
iii. Venous thromboembolism (VTE): The baseline risk
of VTE in adolescents is very low (1 per 10,000). CHC
use is associated with a 3-fold increase risk for VTE Conclusion
with an absolute risk of 3-4 per 10,000 in adolescents.
The ability to freely choose when and how many children to
There currently is inadequate data to support preferential
have is a basic human right. Contraception is an important
prescribing related to increased VTE risk based on type
pillar for the prevention of unintended pregnancy in
of progestin or dose of ethinyl estradiol (82). Prospective
adolescents. HCPs should strive to provide care within
cohort studies do not seem to show a significant
the human rights based framework and to work with
difference in VTE risk by progestin type (83,84). Routine
adolescents to find a method that best meets their personal
thrombophilia screening in adolescents prior to initiating
biopsychosocial needs and that they will be able to adhere
CHC is not advised.
to. Adolescents should have access to a wide range of
iv. BMD: Adolescence is a time of bone mass accrual contraceptive options with LARCs being first line options
which continues up to approximately age 25 years (38). due to their greater effectiveness. However, as LARC uptake
Although data on CHC effects on BMD is conflicting, there increases among adolescents, it is important to incorporate
is currently no evidence supporting increased risks of messages about condom use specifically for STI prevention.

37
Todd N and Black A J Clin Res Pediatr Endocrinol
Contraception for Adolescents 2020;12(Suppl 1):28-40

Healthcare providers must provide counselling that is 13. World Health Organization. Adolescent Pregnancy. 2018. Available
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appropriate to the adolescent, acknowledges how they
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access health care, and is not perceived as directive or
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Authorship Contributions
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Surgical and Medical Practices: Nicole Todd, Amanda Black, the Evidence and Lessons From High-Quality Evaluations. Glob Health
Concept: Nicole Todd, Amanda Black, Design: Nicole Todd, Sci Pract 2017;5:547-570.

Amanda Black, Data Collection or Processing: Nicole Todd, 17. Centers for Disease Control and Prevention. U.S. Medical Eligibility
Criteria for Contraceptive Use, 2016. Morbidity and Mortality Weekly
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Financial Disclosure: The authors declared that this study
contraceptive effectiveness of levonorgestrel-releasing and copper
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